The Sports Preparticipation Exam (Lukacic, 3/23/2022)

Thanks to Dr. Allison Lukacic for her excellent presentation this week on the Preparticipation Exam (aka the other PPE).

A recording of her presentation is available HERE. 

Summary notes:

• 30 million US adolescents participate in organized sports
• there is a legal requirement in all 50 states to have some form of preparticipation exam for student athletes, 29 states use a standardized form
• said form should be signed by parent if athlete is <18
• goal is to maximize safe participation for young athletes, to identify medical conditions that put athletes at risk, identify those that require treatment/rehab prior to participation
• PPE is potentially  the only interaction they have with a healthcare provider (50-90% of athletes do not have a PCP)

PPE. . .

• should occur 6 weeks prior to sports season
• most states require PPE annually 

A thorough history is the most important part of the PPE-- history detects 88% of important medical conditions affecting sports participation, 66% of injuries

• screening for cardiac conditions: have they ever passed out, do they have chest pain, chest pain w/exertion, SOB?
• family history: anyone in family with sudden death during activity, cardiac disease <50, anyone with Marfan's syndrome?
• history of prior injuries: treatment and f/u
• burning sensation in extremities (suggesting cervical spine injuries)
• history of concussion, timing, healing time
• primary care: medications, substance use, supplements, energy drinks, getting in car w/drunk drivers

Physical Exam, key components

• blood pressure>> caution if > 99percentile
• BP >160/100 is cutoff, should be treated prior to participation
• look for secondary causes (caffeine, supplements), work up as needed
• elevated BP contraindication for static exertion (e.g. weightlifting)
• Marfanoid body habitus?
• vision screen (20/40 in at least one eye if want to do archery, rifles)
• lung exam: asthma adequately treated? PFTs if exercise-induced asthma
• cardiac: rate, rhythm, listening for murmurs (supine, standing/sitting w/Valsalva maneuver), PMI
• grade 3 or greater?
• increase with Valsalva maneuver?
• diastolic?
• abdomen: hepatic or splenic enlargement
• genitalia: undescended/single testes (should wear cup), hernia (should be referred for repair), testicular mass
• no genital exam in female
•  musculoskeletal exam, including supplemental knee/shoulder/ankle exams if history of injury
• range of motion in all joints, pain through motions, symmetry
• duck walk quickly assesses all lower extremity joints
• skin: molluscum, scabies, ringworm, HSV, impetigo

EKG, labs, urine drug tests are NOT recommended in standard PPE

Preparticipation Assessment (reminder goal is to get as many kids actively engaged in sports as possible)

1. unrestricted clearance
2. clearance w/notification to coach/trainer (e.g. brace, inhaler)
3. clearance deferred for further evaluation (e.g. echo w/murmur)
4. disqualification (very rare)

Sudden Death

rare, 0.75 per 100K athletes (<35 cases per year in the US)

hypertrophic cardiomyopathy (HCM) is the most common cause of sudden death (36%)

HCM affects approximately 1/500 individuals 

sarcomere mutation in the heart muscle, autosomal dominant

clinical diagnosis: EKG>> echo>> cardiac MRI

exam findings: systolic murmur in left 2nd intercostal space, lateral displacement of apical pulse (PMI), murmur increases in intensity when lying to standing/sitting, w/Valsalva (due to increased venous return)

EKG: LVH, LV strain, deep q waves lateral/inferior leaves, T wave inversion, sometimes WPW (Current US recommendations there is not enough evidence for EKG for all athletes and risk>>benefit, though Italy does do EKG for all PPE because they have evidence it decreased HCM)

2016 California passed Eric Paredes Sudden Cardiac Prevention Act, which requires discussion of sudden cardiac death during the PPE, also specific coach/trainer responsibilities

Exam findings in Marfan's

Female and Male Athlete Triad

in females: menstrual cycles, eating patterns, stress fractures (osteoporosis prevention)

male athlete triad (recently coined), but similar disordered eating, energy deficiency and reproductive dysfunction

athletes with these triad should not be cleared for participation until these issues are addressed

Concussions: important to document duration, frequency and recovery time

• in CA, athletes cannot return to play in less than 7 days from time of concussion (many athletes need a month to recover)
• Major goal to prevent second impact syndrome, chronic traumatic encephalopathy (football, 17+ injuries)
• balance error scoring and neuropsychological testing: all symptoms must resolve prior to return to play

Other medical conditions:

Asthma is a common diagnosis that may need to better controlled prior to clearance

Hemophilia or Von Willebrand's disease: no contact or collision

Sickle cell disease: no high exertion, contact, or collision sports

Sickle cell trait: cleared for ALL sports participation (though there have been deaths of NFL with just trait)

Epilepsy: any sport except w/ risk for fatal seizure (e.g. sky diving)

MSK injuries are the most common injury to have an athlete be restricted

Criteria for clearance: NO joint effusion, no decreased ROM, 80-90% of full strength

Resources:

• National Association of State High School Associations (NFHS)
• Standardized PPE form
• Pediatric Blood Pressure App

Concussion Management in Primary Care (Affleck, Ohkubo, Matthew 9/1/2021)

Many thanks to Dr. Monica Ohkubo,  Dr. Ty Affleck, Athletic Trainer Chelsea Matthew, and DNP Surani Kwon for a great interdisciplinary Grand Rounds presentation from the North Coast Concussion Management team on Concussion Management in Primary Care. 

A recording of their presentation is available HERE. 

Driven by increased attention on head injuries over the last decade, the standard of care for sport-related concussions has changed significantly from a general If you feel okay, it's okay, go back in and play mentality to a much more evidence-based stepwise management approach to concussion. 

• In US, there are 1.3-3.8 million concussions annually, close to 300,000  ER visits (2010-2016)
• In football alone, 7.7% NFL players experience concussion (this amounts to only about 130/year), but if 4-6% of high schoolers also experience concussion, this amounts to 1.2 million/year
• People with history of concussion are more likely to have another
• Hx migraine, depression, insomnia cognitive problems, visual abnormalities-->  concussion can unearth or exacerbate these conditions (learning disability can be activated, depression can represent or be exacerbated)
• Many used to believe that most athletes recovered from concussion in 7-10 days with a few stragglers. . .new evidence has found that after 2 weeks less than 1/2 of athletes with concussion have fully recovered

Initial Concussion Care: "You don't know how bad it is until it's over" -Dr. Ohkubo

• You cannot assign a time frame for recovery as soon as the concussion is recognized  (but by state law, it's always at least 7 days)

• NO return to play in same game/practice
• Monitor for deterioration over the first few hours after injury (s/sx bleed)
• Early follow-up with someone trained
• Physical rest
• Mental rest: no phones, no school/shortened school
• Per state law, any high school athlete with a concussion must follow up with physician trained in concussion management for medical clearance

Best practices for Concussion Management

Standardized Concussion Assessment Tool (SCAT5)

The SCAT-5 is a validated tool to use for concussion evaluation. Includes several components: GCS, c-spine evaluation, symptom evaluation, cognitive tests, balance tests, memory, coordination, and 6 step return to play guidelines. The link above will take you to the full 8 page document.

Of note, the symptom evaluation on the SCAT includes  22 symptoms: physical, emotional, mental, sleep. Different areas can be differentially affected

Athletes also can cover up symptoms because they are used to pushing themselves, so pay attention to the individual answers

Eye and Balance Test

Balance testing (BESS): 20 second each feet together hands on the hip eyes closed, non-dominant leg, tandem stance with non dominant foot in the back

Neurocognitive Testing

Gold standard is baseline testing (pre injury) to be able to assess extent of injury if/when it occurs

SRJC and SRCS are doing this for all athletes: Computerized neurocognitive baseline and f/u testing

Athletic Trainers

 Athletic trainers are (board certified, link between healthcare provider and the athlete and parent) important resource to be able to be available to do concussion training/prevention as well as assist with assessment and return to play protocols

• prevention and recognition of injury, referral, treatment rehabilitation
• academic modification
• objective assessment at sideline, retesting
• referrals for physician, mental health support
• facilitation of return to play protocol
• day to day contact with athletes

Treatment and Management of Concussion

1. Cognitive and physical REST is huge. Academic accommodations have to be provided by doctors specific form that physicians need to fill out (e.g. half days at school, extra time on tests, reduced homework load, note taking, not on computer all the time)
2. Diet: appetite changes after concussion (more/less hungry). Eat small things through the day
3. Hydration: nausea, drinking small amount during the day
4. Sleep: sleep patterns can change (more/less than normal, frequent waking). Don't wake a sleeping athlete. Sleep is important in recovery. Naps: not after 3pm
5. Exertion: people recovering both physical and mental, though small sub-symptom exercise can help recovery. 
6. Stress: interpersonal arguments, emotions can change post concussion, crying out of nowhere (not criers), lights/sound noise: bright lights, fluorescent lights, sunglasses (accommodation), loud sounds (e.g. PE class)
7. Do NOT push the symptoms

Return to Play Process (CA state law)

• Anyone diagnosed with concussion, must go through the process that starts with a medical evaluation, and then start 7 day process
• For contact sports, athletes must get a two step medical clearance
• Each step MUST be separated by at least 24 hours
• If symptoms return at any step, stop the activity, let rest for the rest of the day and return to the same step

***********************************************************

Step#1      Rest until asymptomatic

MEDICAL CLEARANCE

Step#2:     Light aerobic activity (walk around track or football field)

Step#3:     Sport specific exercise (running, swimming)

Step#4:     Non contact training drills (shooting, serving, setting)

MEDICAL CLEARANCE

Step#5:     Contact practice

Step#6:     Contact game

************************************************************

It's important to note that concussion symptoms tend to cluster: "Concussion picks on everyone's weakness". 

Someone may have minimal to no symptoms in one category but profound deficits in another. Directing your attention to where their symptoms are is a key take home. 

• vestibular
• cognitive/fatigue
• ocular
• post-traumatic migraine
• anxiety/mood
• cervical 

Specialists can be helpful depending on the problem: concussion specialist, vestibular rehab, neuro opthamologist, neuropsychologist

Use of neurocognitive tests

Gold standard is to have a baseline and post-test injury test. That way you can compare the two. IF you don't have a baseline, there are standardized scores based on age/educational level that you can use to make your assessment.  

Specifically, the computerized neurocognitive test ImPACT used at SRJC and SRCS (see image below for an example report)

Other tools:

• Vestibular and oculomotor testing (VOMS test)
• A "Home SCAT test": ideally, athletic trainers are supporting the return to play process; however, if there is no athletic trainer to link to care, consider using parent to help athletes get through the process. Have the athlete go through above steps and have parent administer a variation on the SCAT (below)
• Light aerobic exercise (in Dr. Affleck's words, "oxygen") can help speed recovery
• Disrupted sleep? Consider melatonin

Additional References/resources:

CDC: www.cdc.gov/concussion/

UPMC: www.upmcphysicianresources.com

northcoast concussion.org 

CIF physician letter to school: https://cifstate.org/sports-medicine/concussions/CIF_Physician_Letter_to_School_after_Concussion_Visit.pdf